February 2014

In youth athletes, repair after meniscal injury poses challenge

2PEDSmeniscus-iStock169800Obesity, gender affect tear complexity

By P.K. Daniel

Adolescents and children suffer more complex meniscus injuries that are often less repairable than previously reported, according to a study published in the December 2013 issue of the American Journal of Sports Medicine (AJSM).

The study included 293 patients aged between 10 and 19 years who underwent arthroscopic meniscus surgery. Nearly all were active in sports, but factors contributing to greater complexity of the meniscal tears—which can adversely affect repairability—were obesity and male gender.

“Both obesity and boyhood carry an increased capacity for tear potential,” said study author Eric Edmonds, MD, who specializes in orthopedic surgery at Rady Children’s Specialists of San Diego in California.

Meniscal repair has demonstrated better long-term outcomes over partial meniscectomy in adults. A 2010 study showed no evidence of osteoarthritic advancement in 80.8% of patients a mean of 8.8 years after repair compared with 40% after meniscectomy.

“We recommend repair, if we can,” said Kelly Vanderhave, MD, who specializes in pediatric orthopedic surgery at Carolinas HealthCare System in Charlotte, NC. “Previous studies have shown that, if you take it out, you advance arthritis pretty quickly. If it’s at all repairable, I repair it.”

In the AJSM study, adolescent boys had a lower repair rate (41%) than adolescent girls (56%). Nearly one-third (32%) of the boys had complex tears, compared with just 20% of the girls studied, which also translated to lower repair rates among boys. Patients with complex tears also had a significantly higher body mass index than those with noncomplex tears (27.4 vs 25.1), though the study did not examine the relationship between body mass index and repair rates.

Meniscal injuries often present with other acute injuries such as anterior cruciate ligament (ACL) tears, chondral injuries, and tibial fractures. Although the correlation hasn’t been studied specifically, it’s likely that, just as pediatric anterior cruciate ligament (ACL) injury rates are on the rise, so too are pediatric meniscal injuries, Vanderhave said.

“They tend to go together,” Vanderhave said. “I think kids’ activity levels have increased overall. The number of sports injuries I see now is ten times what I saw ten years ago.”

Not all of the meniscal tears in the AJSM study were associated with ACL or other ligament injuries. The presence of ligament injury didn’t affect meniscal repair rates, said study coauthor Andrew T. Pennock, MD, who also specializes in orthopedic surgery at Rady Children’s Specialists of San Diego.

However, the authors did find that earlier treatment may increase the likelihood of repair in younger patients. Those treated within three months of injury were most likely to have repair, at a rate of 56%, compared with only 42% who were treated more than six months after injury. The repair rate for adolescents was even more dramatic, dropping from 58% at three months to 37% at six months.

Pennock noted a variety of reasons why surgeries are sometimes deferred, but delayed presentation led the list.

“Some are delayed presentation—the football player who didn’t want to come in midseason—some are patients who underwent a nonoperative course that failed, and others are delays in the workup, including a referral to the orthopedic surgeon, an MRI, and surgical booking or authorization,” he said.

Such delays increase the likelihood that a young, active patient will do further damage to the initial injury.

“Kids are very determined and resilient,” Edmonds said. “They often push through injuries because they don’t have the life experience to understand that you cannot just bounce back from all boo-boos. In that process, they continue to extend the injury past its original configuration. This can change from fixable to nonfixable.”

The surgical approach was typically determined by the type of the meniscal tear, in conjunction with the tear location, patient age, and chronicity of the tear. In the vast majority, surgeons did a partial meniscectomy if a repair was not possible.

“The reparability of the meniscus tear was determined by the surgeon at the time of surgery,” said Pennock. “In general, less complex tears in the red-white or red-red zone [at the outer edge of the meniscus] have the best healing potential and are the most likely to be repaired.”

P.K. Daniel is a freelance writer and editor based in San Diego, CA.

Sources:

Shieh A, Bastrom T, Roocroft J, et al. Meniscus tear patterns in relation to skeletal immaturity: children versus adolescents. Am J Sports Med 2013;41(12): 2779-2783.

Stein T, Mehling AP, Welsch F, et al. Long-term outcome after arthroscopic meniscal repair versus arthroscopic partial meniscectomy for traumatic meniscal tears. Am J Sports Med 2010;38(8):1542-1548.

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